In the absence of really big biosimilar stories with far-reaching implications, let’s start with some interesting bits on biosimilars to begin this week.
First, insulin maker Eli Lilly asked the Food and Drug
Administration a very interesting question, in comments
on the agency’s guidelines on transitional drugs. Lilly requested clarification
of the rules under which it might introduce an authorized brand of insulin
(that is, a lower-priced version of an existing insulin brand). The insulins
are one group of medicines that is scheduled to transition to regulation under
the Public Health Services Act in 2020, and thus be subject to formal biosimilar
Second, Boehringer Ingelheim, which received FDA approval to market its adalimumab biosimilar Cyltezo® in August 2017, received a positive ruling in its patent litigation case with AbbVie. A federal court judge ruled that AbbVie, which makes the originator product Humira® must turn over all papers related to the Humira patents. This may actually move the court case out of the discovery phase, according to Fierce Healthcare, and potentially closer to an actual, early biosimilar launch. Third, Health Canada has decided not to add a four-character suffix onto the names of its biosimilars and biologics. Instead, it will rely on its specific drug identification number as well as the nonproprietary names to identify medications being taken. This of course, contrasts with the FDA’s practice. The FDA is the only major advanced regulatory system that requires the use of a suffix to distinguish biosimilars and their reference products. And it is not used by providers.
On December 11, the Commissioner of the Food and Drug Administration (FDA), Scott Gottlieb, MD, issued a far-ranging statement on actions to be taken by the federal government to improve access to biosimilars and to begin the transition of insulins, growth hormones, and other selected drugs to biologic status, under section 351 of the Public Health Service Act.
“Today, we’re taking additional actions to advance this framework,” stated Dr. Gottlieb. “Among them, we’re issuing four new draft guidance documents today. The first two guidance documents provide greater clarity on scientific and regulatory considerations for the development of biosimilar and interchangeable products. We intend to update these new guidance documents regularly, to address development issues as they evolve.”
These guidance documents, created in question-and-answer format, address specific issues, some of which get to the heart of biosimilar development and access. For example, one section speaks to abuse of limited distribution systems requirements, in connection with Risk Evaluation and Mitigation Strategy (REMS) programs. These programs have been used as a way to “delay or derail access to reference product samples that biosimilar sponsors need for testing to support their applications for a biosimilar product.” Dr. Gottlieb said, “While the limited distribution programs can have a role in promoting patient safety, too many branded products are still misusing these programs as rhetorical smokescreens to hide anti-competitive behavior.”
Dr. Gottlieb said that FDA will, upon request only, “review study protocols submitted by biosimilar applicants to assess whether their protocols contain comparable safety protections to those in the REMS for the reference product they’re trying to reference.” The FDA will be willing to state in a letter to the reference manufacturer “that comparable protections exist, and that the FDA won’t consider it to be a violation of the branded drug company’s REMS to provide the biosimilar sponsor with a sufficient quantity of the reference product to perform testing necessary to support its biosimilar application.”
He also reiterated that it may be possible for biosimilar developers to obtain EU-licensed samples for use in comparative studies. Dr. Gottlieb indicated that the FDA was still evaluating this option.
New Routes of Administration for Biosimilars not Allowed
Another Q&A would put to rest the notion that a biosimilar maker can produce a new formulation or route of administration for an approved biosimilar product under the 351(k) pathway. The guidance states, “An applicant may not seek approval, in a 351(k) application or a supplement to an approved 351(k) application, for a route of administration, a dosage form, or a strength that is not the same as that of the reference product.” This would mean development of a subcutaneous form of infliximab, for example, would not be possible under the biosimilar regulatory pathway, because Remicade® is only available as an intravenous infusion.
On the Road Toward Interchangeable Insulins
One of the key provisions of the BPCIA is that insulins, growth hormones, and other agents for which reference products were not available under the FD&C Act, will be transitioned to the biologic regulatory pathway (under the Public Health Services Act) by 2020. The FDA has begun to consider just how this will occur.
Starting in March 2020, this transition will take place. “Today, we’re laying out our policy on how these products will transition from the drug pathway to the biologics pathway, and in so doing, how we intend to use this new framework to promote competition,” said Dr. Gottlieb.
Under the “Deemed to be a License” Provision of the Biologics Price Competition and Innovation Act of 2009,” the final guidance from the FDA specifies that these newly deemed biologics will be subject to the same regulations as today’s biosimilars. “Anti-evergreening provisions under the biosimilars legislation—meant to prevent sponsors from being able to game the exclusivity provisions to forestall biosimilar entry—will apply to these newly deemed products, including insulin.”
Furthermore, these agents will not gain any additional exclusivities because of the transition (they will not get any additional exclusivity). It is assumed that once they are transitioned, and if their patents have expired, biosimilar competition can begin at once. This could mean far greater pricing pressure on insulin products (not simply glargine), and potentially even interchangeable designations that can be automatically substituted at the pharmacy.
As part of this transition, Dr. Gottlieb explained, biological products that have been approved under section 505 of the FD&C Act will be removed from the FDA’s Orange Book on March 23, 2020, based on the agency’s position that these products are no longer ‘listed drugs.’ That means that a follow-on applicant won’t be able to rely upon these NDAs for approval. They have to go down the biosimilars path after the transition.”
Payers, providers, and patients in the US are narrowly focused on a limited set of biosimilar products; we all know them well—the anti-TNFs, the colony-stimulating growth factors, and most recently some antitumor drugs (e.g., trastuzumab, rituximab, and bevacizumab). In 2020, before the first biosimilar to Humira® hits the market, some medications may be reclassified as biosimilar status.
Tucked away in the Biologics Price Competition and Innovation Act of 2009 (BPCIA) is a set of obscure provisions that has the potential to create a good deal of confusion at that time.
“Transition drugs.” If you’re familiar with the term, you’re one of the few. Some medications are “transitioning” in the next couple of years. Specifically, drugs that will be transitioned include the insulins, but also other naturally occurring proteins, such as hyaluronidase, human growth hormones, and menotropins.
The mechanism is actually quite simple. Today, these products are all approvable under the original Food, Drug, and Cosmetics (FD&C) Act of 1962. By 2020, these agents will be approvable as biologics under the BPCIA. That means that they will not only be categorized as a biologic, but they will be subject to biosimilar—not generic—competition. No more new drug applications or abbreviated new drug applications, only biologic license applications of the 351(a) and 351(k) varieties.
In March 2016, the Food and Drug Administration (FDA) issued draft guidance on these transitional products. As the Regulatory Affairs Professional Society described it earlier this year, “Put simply: FDA will not approve any pending or tentatively approved application for a biological product under the Federal [FD&C] Act after 23 March 2020.”
This may have the effect of slowing approval of today’s so-called follow-on biologics, which will have to go through the 351(k) application process. For example, Lilly received approval for its insulin glargine product under a 505(b)2 application. This application process allowed Lilly to use clinical data from Sanofi’s originator product Lantus®. Under the letter of the new law, because no insulin glargine product has been approved via the biologic license application route, there are no “reference” or originator insulin products.
This can result in labeling and exclusivity period issues as well, possibly discouraging manufacturers of these products from applying for FDA approval. “Nothing in the [BPCIA] suggests that Congress intended to grant biological products approved under section 505 of the FD&C Act—some of which were approved decades ago—a period of exclusivity upon being deemed to have a license under the PHS Act that would impede biosimilar or interchangeable product competition in several product classes until the year 2032,” FDA said.
A legislative proposal was introduced in 2015 by Representative Michael Burgess (R-TX), which would have asked the Government Accountability Office to review the provisions and their potential impact before the 2020 transition took place. The proposal did not advance in the House.
A search revealed no updates on the legislative or regulatory sides of the fence, so we assume the transition will occur as intended. Currently stated policy by the FDA is that all biologics will receive a new four-character suffix to their nonproprietary names. Will this apply to the older insulins and growth hormones as well? Will coding, descriptors, or nomenclature for Lantus® have to change to reflect a new status as a reference biologic product? Or will this only apply to medications approved after March 2020 (in which case, there could be a confusing dichotomy here).
You know it’s been a pretty desperate week in the biosimilar blogosphere when twitter feeds relate back to articles published in January, rehashes of the US Supreme Court decision in June, or yet another estimate of the savings potentially ascribed to biosimilar use (based on erroneous assumptions). However, there were a few significant tidbits announced last week that are worth reviewing.
First, Biocon announced that the decision to approve its trastuzumab biosimilar (with partner Mylan) has been delayed by the Food and Drug Administration (FDA) 3 months (until December 3, 2017). According to Biocon, this delay was required so that the FDA could “review some of the clarificatory information submitted as part of the application review process.” Clarificatory? Really? Maybe the extra time was needed to translate the application itself.
Second, a survey of 103 US gastroenterologists raised a couple of questions as to how well information about Inflectra®, the biosimilar to Remicade®, is sinking in on the practice level. According to a press release from Spherix Global Insights, cross-category prescribing may be interfering with the uptake of the biosimilar. They state, “not only is the decline [in Remicade prescriptions] attributed to the adoption of infliximab biosimilars, but use of Humira® has also significantly increased, potentially indicating that more ulcerative colitis patients are being placed on Humira to avoid insurance mandates for infliximab biosimilar use.” This limited survey found that more than one-third of gastroenterologists “agree that if a pharmacy or managed care plan advises them to use Inflectra over Remicade, that they are more likely to choose a different TNF-inhibitor altogether.” This is a weird finding, perhaps indicating nothing more than spite for the health plan’s benefit design. Clearly, if the physicians fully considered the evidence, they would be less likely to prescribe in this way. Admittedly, as notable numbers of managed care organizations have not actually mandated Inflectra use at this point in time, we would have to wait to see if this opinion is validated in actual practice.
Finally, Sanofi announced that it had received tentative approval on a follow-on biologic form of insulin lispro (the originator product was Lilly’s Humalog®). Patent issues will have to be resolved before Sanofi can receive final approval and bring this product to the market. The insulin biosimilars are not regulated under the Biologics Price Competition and Innovation Act, but rather under the Hatch–Waxman Act—the application was filed as a 505(b)2 rather than a 351(k) variety. They are transitional products, which will considered under the newer regulations after March 23, 2020. We will detail these lesser-known transitional drug categories in a future post.
The US Food and Drug Administration gave its approval on July 20 to Merck’s version of insulin glargine. Although not technically a biosimilar, it is suffering a fate like that of multiple biosimilars—approved but in launch limbo owing to patent litigation issues.
Merck applied for approval of its insulin product under the 505(b)(2) pathway (not the 351[k] biosimilar pathway), which essentially makes it another biologic brand, not a biosimilar. The first insulin glargine follow-on product, Basaglar® (Lilly), utilized the same abbreviated pathway to approval; however, Lilly agreed to a patent settlement with the originator manufacturer, Sanofi, allowing Lilly to launch Basaglar in December 2016. Merck performed separate clinical studies to prove its product’s noninferiority to Lantus®, as well as relying on Lantus data in its application.
Under Hatch-Waxman Act rules, Merck will have to either wait for the final positive ruling by the US District Court in Delaware on the patent litigation or 30 months after the initial filing of Sanofi’s lawsuit (in September 2016), whichever is earlier. This could potentially result in a launch in 2019, providing a compelling incentive for Merck to come to a licensing agreement with Sanofi.
In another connection with biosimilars, Merck developed the drug along with its biosimilar partner Samsung Bioepis.
Whenever the launch takes place, Merck will brand their insulin glargine drug Lusduna Nexvue, which will be available as a prefilled syringe.
Competition among insulin makers is intense. In most cases, manufacturers realize that various forms of insulin are well matched in clinical efficacy and safety by competing insulin makers. The only real differentiator among the products may be how the insulin is delivered. In fact, these manufacturers spend a tremendous amount of design research, engineering, testing, and market research resources in producing a delivery device that patients will find relatively comfortable, easy to use, and portable (see example). It brings to mind an executive for a major insulin producer who I had repeatedly seen stabbing himself with a pen-type injection device (without insulin) to demonstrate to others that the delivery system and the narrow-gauge needle was about as pain-free as possible to engineer.
This raises the question of whether a patient with diabetes mellitus whose glycemic levels are under control are actually loyal to the insulin brand or its delivery system. In reality, however, health plans and insurers pay far more attention to the insulin formulation than to the insulin delivery device in making coverage decisions. In some cases, they may cover only certain types of delivery systems, yet this seems to contradict the precepts of value-based benefits (providing best access to interventions that are proven to improve diabetes control and/or adherence). Health plans and insurers may instead focus on other aspects of the insulin itself, such as whether it has a relatively lower risk of hypoglycemic events.
A few years ago, the question about which basal insulin to cover was straightforward, usually amounting to pricing, rebates, and existing marketshare (e.g., how difficult it might be to switch the majority of patients who were taking Lantus® to Levemir®). This was no different than other competitive drug categories. The introduction of the first follow-on (or let’s face it, biosimilar) insulin glargine (Basaglar®) has added new impetus to this discussion. Lilly, the company licensing Basaglar, won a couple of big coverage victories for 2017 over Sanofi’s Lantus, including CVS Health and UnitedHealthcare. The partnership of Merck and Samsung Bioepis hope to receive a positive FDA decision on their insulin glargine biosimilar in the third quarter of this year. Lilly, a veteran of the insulin wars, promotes the use of its existing KwikPen® system for Basaglar. Should Merck get a positive decision, it will market another pen-delivery system. (For the record, Merck is not a complete stranger to the insulin market. It does have an insulin product marketed to the veterinary sector, with its own pen-delivery system [VetPen®]). This raises the question of whether the biosimilar must be paired with its own, perhaps prefilled pen-delivery device and whether it results in the same or similar patient satisfaction ratings. This could have implications for adherence and thus glycemic control.
The US continues to lag behind Europe in terms of pen-injector use (more than two-thirds of patients in Europe use pen-based systems, whereas only 15% use pens in the US), where needles and syringes still dominate. The reasons for this are likely related to reimbursement or patient cost sharing. For those using needles and syringes, the payer’s preference for insulin glargine is more straightforward.
However, as the patents of this and other insulin analog molecules expire, it is reasonable to expect the availability of biosimilar or follow-on copies to increase, making the drug-delivery system pairing even more important.